FUGL- MEYER ASSESSMENT OF PHYSICAL PERFORMANCE



FUGL- MEYER ASSESSMENT OF PHYSICAL PERFORMANCE Lower Extremity

PROCEDURE

Description: This assessment is a measure of lower extremity (LE) motor and sensory impairment.

Equipment: A chair, bedside table, reflex hammer, cotton ball, stop watch, and blindfold.

Administration: Perform the assessment in a quiet area when the patient is maximally alert. The complete assessment usually requires 15 minutes.

General Rules

Perform the assessment in a quiet area when the patient is maximally alert.

Volitional movement assessment: This includes flexor synergy, extensor synergy, movement combining synergies, movement out of synergy, and coordination/speed. For all tests of volitional motion, these guidelines are to be followed:

1. Give clear and concise instructions. Mime as well as verbal instructions permissible.

2. Have subject perform the movement with non-affected extremity first.

3. Repeat each movement 3x on the affected side and score best performance. If full score is attained on trials 1 or 2, do not have to repeat 3 times. Only test Coordination/speed, one time.

4. Do not assist subject, however verbal encouragement is permitted.

Fugl-Meyer Motor Assessment

Lower Extremity

I. Reflex activity (1a and 1b)

• Subject is supine or sitting.

• Attempt to elicit the Achilles and patellar reflexes.

• Assess the unaffected side first.

• Test affected side.

• Scoring (Maximum possible score = 4):

• (0) - No reflex activity can be elicited;

• (2) - Reflex activity can be elicited. Items to be scored are Achilles and patellar reflexes.

IIA. Flexor synergy (2a, 2b, 2c)

• Subject is supine.

• Have patient perform movement with unaffected side first.

• On the affected side, check subject’s available PROM at each joint to be tested.

• Start with leg fully extended at hip, knee, and ankle. Instruct the subject to “bring your knee to your chest” (therapist is observing for evidence of hip, knee, ankle flexion in order to assess the presence of all components of the flexor synergy). Therapist can cue the patient to move any missing component.

• Test 3x on the affected side and score best movement at each joint.

• Scoring (Maximum possible score = 6):

• (0) - Cannot be performed at all

• (1) – Partial motion

• (2) – Full motion

Items to be scored are: Hip flexion, knee flexion, ankle dorsiflexion.

IIB. Extensor synergy (2d, 2e, 2f, 2g)

• Subject is sidelying.

• Have patient perform movement with unaffected side first.

• On the affected side, check subject’s available PROM at each joint to be tested.

• Start in 90 degrees hip flexion, 90 degrees knee flexion and ankle dorsiflexion.

• Instruct the subject to "push your foot down and kick down and back”. (Ankle plantarflexion, knee extension, hip adduction and hip extension.)

• Slight resistance should be applied in adduction which is gravity-assisted in this position to ensure subject is actively doing it.

• Test 3x on the affected side and score best movement at each joint.

• Scoring (Maximum possible score = 8):

• (0) – No motion

• (1) – Partial motion

• (2) – Full motion

Items to be scored are: Hip extension, hip adduction, knee extension, ankle plantarflexion.

III. Movement combining synergies (in sitting) (3a, 3b)

3a. Knee flexion beyond 90°:

• Subject is sitting, feet on floor, with knees free of chair. Knee to be tested is slightly extended beyond 90° knee flexion. Calf muscles should not be on stretch. To decrease friction, subject’s shoes can be removed, but socks should remain on.

• Have patient perform movement with unaffected side first.

• Subject is instructed to "pull your heel back and under the chair."

• Test 3x on the affected side and score best movement.

• Scoring (Maximum possible score = 2):

• (0) – No active motion

• (1) – From slightly extended position, knee can be flexed but not beyond 90°

• (2) – Knee flexion beyond 90°

3b. Ankle Dorsiflexion:

• Subject is sitting, feet on floor, with knees free of chair. Calf muscles should not be on stretch.

• Have patient perform movement with unaffected side first.

• On the affected side, check subject’s available PROM at the ankle joint.

• Subject is instructed to "keeping your heel on the floor, lift your foot."

• Test 3x on the affected side and score best movement.

• Scoring (Maximum possible score = 2):

• (0) – No active motion

• (1) – Incomplete active flexion (heel must remain on floor with medial and lateral borders of the forefoot clearing the floor during dorsiflexion)

• (2) – Normal dorsiflexion (full within available ROM, heel remains on the floor)

IV. Movement out of synergy (Standing, hip at 0 degrees) (4a, 4b)

4a. Knee Flexion:

• Subject is standing, hip at 0 degrees (or full available ROM up to 0 degrees). On leg that is being tested, hip is at 0 degrees (or full available ROM up to 0 degrees), but the knee is flexed, and the subject’s toes are touching the floor slightly behind. Evaluator can provide assistance to maintain balance and subject can rest hands on a table.

• Have patient perform movement with unaffected side first.

• Subject is instructed to "keeping your hip back, kick your bottom with your heel."

• Test 3x on the affected side and score best movement.

• Scoring (Maximum possible score = 2):

• (0) – Knee cannot flex without hip flexion

• (1) – Knee flexion begins without hip flexion but does not reach to 90° or hip begins to flex in later phase of motion

• (2) – Knee flexion beyond 90° (Knee flexion beyond 90 degrees with hip maintained in extension)

4b. Ankle Dorsiflexion:

• Subject is standing, hip at 0 degrees. If subject’s calf muscle length is limiting active dorsiflexion in this starting position, then leg that is being tested can be positioned forward, so the hip is at approximately 5 degrees of flexion, and calf muscles are in lengthened position. Knee must stay fully extended. Evaluator can provide assistance to maintain balance and subject can rest hands on a table.

• Have patient perform movement with unaffected side first.

• On the affected side, check subject’s available dorsiflexion PROM.

• Subject is instructed to "keeping your knee extended and your heel on the floor, lift your foot."

• Test 3x on the affected side and score best movement.

• Scoring (Maximum possible score = 2):

• (0) – No active motion

• (1) – Partial motion (less than full available range with knee extended; heel must remain on floor with medial and lateral borders of the forefoot clearing the floor during dorsiflexion)

• (2) – Full motion (within available dorsiflexion range with knee extended and heel on the floor)

V. Normal Reflexes (sitting) (5)

• ONLY DONE IF THE SUBJECT ATTAINS A SCORE OF 4 ON SECTION IV (i.e., if the subject does not score a 2 on each of the previous items, then score this item 0).

• The examiner shall elicit patellar and Achilles phasic reflexes with a reflex hammer and knee flexors with quick stretch of the affected leg and note if the reflexes are hyperactive or not.

• Scoring (Maximum possible score = 2):

• (0) - At least 2 of the 3 phasic reflexes are markedly hyperactive

• (1) – One reflex is markedly hyperactive or at least 2 reflexes are lively

• (2) - No more than one reflex is lively and none are hyperactive

VI. Coordination/speed - Sitting: Heel to opposite knee repetitions in rapid succession. (6a, 6b, 6c)

• Subject positioned in sitting with eyes open.

• Have patient perform movement with unaffected side first.

• Subject is instructed to "Bring your heel from your opposite ankle to your opposite knee, keeping your heel on your shin bone, move as fast as possible."

• Use a stopwatch to time how long it takes the subject to do 5 full (ankle to knee to ankle) repetitions.

• Use the full achieved active ROM in the unaffected limb as the comparison for the affected limb. If active ROM of affected limb is significantly less than that of affected limb, patient should be scored “0” for speed.

• Repeat the same movement with the affected leg. Record the time for both the unaffected and affected sides. Observe for evidence of tremor or dysmetria during the movement.

• Scoring Tremor (Maximum possible score = 2):

• (0) - Marked tremor

• (1) – Slight tremor

• (2) – No tremor

• Scoring Dysmetria (Maximum possible score = 2):

• (0) - Pronounced or unsystematic dysmetria

• (1) – Slight or systematic dysmetria

• (2) – No dysmetria

• Scoring Speed (Maximum possible score = 2):

• (0) - Activity is more than 6 seconds longer than unaffected leg

• (1) – 2-5.9 seconds longer than unaffected leg

• (2) - less than 2 seconds difference

• NOTE: This item attempts to discriminate between basal ganglia, thalamic, or cerebellar strokes in which tremor or dysmetria may result as a direct result of lesion to these areas. The majority of stroke cases are in the middle cerebral artery or basilar artery where we expect to observe paralysis that affects movement speed but does not cause tremor or dysmetria. In cases of complete paralysis, observe for any indication of tremor or dysmetria that may be evident in face, voice, arms or legs. If there are no indicators of tremor or dysmetria, then score these items 2 and score speed 0.

SENSORY ASSESSMENT

a) Light touch:

Procedure:

• The procedure can be tested in the sitting or supine positions. Explain to the patient with their eyes open, “I am going to touch you with this cotton ball and I would like you to tell me if you can feel that you are being touched.” Lightly touch patient with cotton ball over the unaffected muscle belly. Ask them, “Can you feel that you are being touched?” This part of the procedure confirms that the patient understands the test.

• Explain to the patient, “I am going to ask you to close your eyes. Then I am going to touch you with the cotton ball on your right/left (unaffected) side followed by your right/left (affected) side. When I ask you, tell me if you can feel the touch.” Ask the patient to close their eyes. Lightly touch unaffected area with cotton ball and ask, “Do you feel this?” Lightly touch affected area with cotton ball and ask “Do you feel this?“ If the patient says they feel the touch on both sides, then repeat the procedure by touching first the unaffected side immediately followed by the affected side and ask the following question. “Does ‘this’ (unaffected area touch) feel the same as ‘this’ (affected area touch)?” The intent is to determine if there are differences in the characteristics of the touch between the two sides.

• If the tester is not confident that the patient understands this procedure or that the response is inconsistent, the tester may confirm their impression by using the following procedure. With the eyes closed, touch the patient on the affected side and ask them to point to where they were touched with the unaffected side. If the patient does not recognize that they are being touched, the score would be absent. If they recognize the touch but are not accurate on the localization, the score will be impaired. If they recognize the touch and are accurate on the localization, the score will be intact.

Upper Extremity (1a, 1b)

Upper arm: Follow above procedure by touching patient over the unaffected and affected biceps muscle belly.

Palmar surface of the hand: Follow above procedure by touching patient over the unaffected and affected palmar surface of the hand.

Lower Extremity (1c, 1d)

Thigh: Follow above procedure by touching patient over the unaffected and affected thigh of the leg.

Sole of foot: Follow above procedure by touching patient over the unaffected and affected sole of the foot.

Scoring :

(0) – Absent - If the patient states that he does not feel the touch on the affected side, the score is absent.

(1) – Impaired - If the patient states that he feels the touch on the affected side and the touch does not feel the same between affected and unaffected sides or the response is delayed or unsure, the score is impaired.

(2) – Intact - If the patient states that he feels the touch on the affected side and the touch feels the same between affected and unaffected sides, the score is intact.

b) Proprioception:

Procedure:

• Proprioception can be tested in the sitting or supine positions for the upper extremity and in supine for the lower extremity. Start with the unaffected limb. Explain to the patient with their eyes open, “I am going to move your arm. This is up; this is down (demonstrate test). I want you to close your eyes and tell me if I am moving you up or down.” Use the hand positions described below for each joint movement.

• Move the joint through a small range of motion (approximately 10 degrees for the limb joints and 5 degrees for the digit joints of the hand and foot). Move the limb at least 3 times in random directions. If the subject is wrong on any direction, then add several more repetitions to determine if the accuracy is great than 75% (score 2) or 75% or less (score 1).

• Start with the most proximal limb joint on the unaffected side. Move to the same joint on the affected side. The intent is to determine if there are differences in the perception of proprioception between the two sides. For example, if the subject identifies the movement stimulus with the same accuracy and responsiveness of the unaffected side then the score would be 2. However, if the subject is accurate but responses are delayed or unsure then the score would be 1. (At this point, you could ask the subject if the movement on this side feels the same as the other side). No perception of joint movement is scored 0.

Upper Extremity (2a, 2b, 2c, 2d)

Shoulder: Therapist supports patient’s arm by the medial and lateral epicondyles of the humerus and at the distal ulnar and radius. Have patient look at arm. Move shoulder, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your shoulder in either direction. I want you to tell me “up” or “down.” Randomly move arm approximately 10 degrees, 4 times (more if needed), keeping track of correct responses.

Elbow: Therapist supports patient’s arm by the medial and lateral epicondyles and

the distal ulnar and radius. Have patient look at elbow. Move elbow, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your elbow in either direction. I want you to tell me “up” or “down.” Randomly move elbow approximately 10 degrees, 4 times (more if needed) keeping track of correct responses.

Wrist: Therapist supports patient’s wrist at the distal ulna and radius and the heads of the 2nd and 5th metacarpal. Have patient look at wrist. Move wrist, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your wrist in either direction. I want you to tell me “up” or “down.” Randomly move wrist approximately 10 degrees, 4 times (more if needed), keeping track of correct responses.

Thumb: Therapist supports patient’s thumb proximal to the interphalangeal joint and either side of the most distal aspect of the thumb. Have patient look at thumb. Move thumb at interphalangeal joint, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your thumb in either direction. I want you to tell me “up” or “down.” Randomly move thumb approximately 10 degrees, 4 times (more if needed), keeping track of correct responses.

Lower Extremity (2e, 2f, 2g, 2h)

The hip and knee should be tested in the supine position. The ankle and toe can be tested in the supine or sitting position.

Hip: Therapist supports patient’s leg at the femoral condyles and the medial and lateral malleolus. Have patient look at leg. Move hip, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your hip in either direction. I want you to tell me “up” or “down.” Randomly move hip approximately 10 degrees, 4 times (more if needed), keeping track of correct responses.

Knee: Therapist supports patient’s leg at the femoral condyles and the medial and lateral malleolus. Have patient look at knee. Move knee, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your knee in either direction. I want you to tell me “up” or “down.” Randomly move knee approximately 10 degrees, 4 times (more if needed), keeping track of correct responses.

Ankle: Therapist supports patient’s leg at the medial and lateral malleoli and the heads of the 1st and 5th metatarsal. Have patient look at ankle. Move ankle, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your ankle in either direction. I want you to tell me “up” or “down.” Randomly move ankle approximately 10 degrees, 4 times (more if needed), keeping track of correct responses.

Toe: Therapist supports patient’s toe at the interphalangeal joint and either side of the most distal aspect of the great toe. Have patient look at great toe. Move interphalangeal joint, saying “This is up. This is down.” I am now going to have you close your eyes and I’m going to move your big toe in either direction. I want you to tell me “up” or “down.” Randomly move great toe approximately 10 degrees, 4 times (more if needed), keeping track of correct responses.

Scoring:

(0) – Absent (no sensation)

(1) – Impaired (three quarters of answers are correct, but considerable difference in sensation compared with unaffected side)

(2) – Intact (all answers are correct, little or no difference).

References

1. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand J Rehabil Med 1975; 7:13-31.

2. Fugl-Meyer AR. Post-stroke hemiplegia assessment of physical properties. Scand J Rehabil Med 1980; 7(Suppl): 85-93.

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